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Menstrual Suppression Using Oral Contraceptives by Female Hajj Pilgrims

Article  in  The International Journal of Travel Medicine and Global Health · November 2016
DOI: 10.21859/ijtmgh-040405

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Int J Travel Med Glob Health. 2016 Dec;4(4):111-114 doi 10.21859/ijtmgh-040405
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International Journal of Travel Medicine and Global Health

Original Article Open Access

Menstrual Suppression Using Oral Contraceptives by

Female Hajj Pilgrims
Wealeed Dandehbor1, Majid Kazemi2*, Mohammad Hossein Salehi Shahrbabaki3, Zohre Ghorashi4,
Rezvan Sadrmohammadi5, Bonnie Bozorg6, Reza Bidaki7,8
1
Deputy of Medical Centre Hajj and Plgrimage of Iranian Red Crescent Society, Tehran, Iran
2
Department Medical Surgical Nursing, Faculty of Nursing and Midwifery, Rafsanjan University of Medical Sci-
ences, Rafsanjan, Iran
3
Rafsanjan University of Medical Sciences, Rafsanjan, Iran
4
Department of Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
5
Department of Clinical Psychology, Kar Higher Education Institute of Rafsanjan, Rafsanjan, Iran
6
Tehran University of Medical Sciences, Tehran, Iran
7
Research center of Addiction and Behavioral sciences, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
8
Diabetes Research Center, Shahid Sadoughi University of Medical Science, Yazd, Iran

Corresponding Author: Majid Kazemi, Ph.D., Associate Professor of Surgical Nursing, School of Nursing, Rafsanjan
University of Medical Sciences, Rafsanjan, Iran. Tel: 03434255900; Fax: 03434258497; Email: maj_kaz@yahoo.com

Received September 3, 2016; Accepted October 20, 2016; Online Published December 5, 2016

Abstract
Introduction: The pilgrimage to Ka’beh (God’s house in Mecca) is a special opportunity in the life of most Muslims. Female
pilgrims try to postpone menstruation during the pilgrimage by taking hormonal medicines. However, women are seen in this
disorder. This paper aimed to determine the frequency of menstrual disorders and related factors among female pilgrims of Umrah
Mufradah in 2012.
Methods: This study was a descriptive type, the population of which comprised 400 female Iranian pilgrims aged 15-50 years who
were selected through random cluster sampling from Umrah caravans. Data was collected with a questionnaire developed by
the researchers that contained questions about menstrual disorders. The questionnaire was distributed among participants at their
hotels three days prior to their return to Iran.
Results: Among all the participants, 98.7% of them reported taking pills to suppress menstruation. Of this group, 74.7% successfully
prevented menstruation, 26% reported spotting, and 11.6% reported menstruation. There was no significant difference between
consumption of medicine and factors such as marital status, city, and educational background of the individuals. Participants
reported that spotting and menstruation caused them to experience stress and anxiety when performing Umrah rituals.
Conclusion: Experiencing menstrual disorders during pilgrimage can be stressful for pilgrims. To reduce such problems, counseling
sessions on menstruation postponement as part of the justification classes before departing for Hajj and compiling an equal and
coordinated nationwide protocol seem necessary.
Keywords: Menstrual, Oral contraceptives, Hajj pilgrims

Citation: Dandehbor W, Kazemi M, Salehi Shahrbabaki MH, et al. Menstrual suppression using oral contraceptives by female Hajj pilgrims. Int J
Travel Med Glob Health. 2016;4(4):111-114. doi:10.21859/ijtmgh-040405.

Introduction enter mosques or say their prayers while menstruating.2

The Hajj ceremony is the most important life event for any
Muslim.1 For the majority of pilgrims, it is a long-desired
journey that may happen only once in a lifetime. Annually,
millions of Muslims from various countries gather in the holy
cities of Mecca and Medina in the Kingdom of Saudi Arabia
to perform their religious rituals.2-4
According to religious instructions, purity or cleanness
is a condition for entering Masjed Al’Haram (the respected
mosque) or other mosques. Women are not permitted to
To take the greatest advantage of their pilgrimage, many
women of reproductive age try to prevent menstruation
during the pilgrimage3 by taking oral hormonal medicines.
The first case of taking medicine to postpone menstruation
dates back to 1977.3 Today, this method is used to decrease
the number of menstruation cycles. Similar utilization of
hormonal medicines is common among Jewish females.4
Definitely, delaying menstruation by taking hormonal
medicines intermittently and for short periods to remove

Copyright © 2016 The International Journal of Travel Medicine and Global Health. This is an open-access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Dandehbor et al

impediments to religion, is regarded as a special case and has
its own side effects and problems.5 Usually, women who are
willing to use this method of prevention have not taken these
medicines before and are more likely to experience more side
effects. The emotional effects of contraceptive pills can be
worse than their physical effects.6 The inefficiency of these
medicines in delaying menstruation appears mainly in the
form of spotting during consumption and can endanger the
main philosophy of consumption, to remove impediments
to religion, and cause stress and other problems for the
consumers. Some studies have investigated the consumption
of these medicines, and spotting while on the medicine
has been reported as a main complaint of pilgrims.2,7 Some
women who use contraceptive pills during their pilgrimage
experience side effects. The most important and most
commonly occurring side effect of the contraceptive pill is
spotting, which can lead to anxiety and depression.
Based on informal reports of menstrual disorders among
pilgrims in Mecca, the current study aimed to determine
the prevalence of menstrual disorders and related factors in
Mufradah pilgrims in 2012.
% of them were single, and 80.8 % were married. The results
indicated that 53.2% were housewives, 44.7% had a bachelor’s
degree or higher, and 2% of them were illiterate.
Results indicated that 98.7% of participants reported taking
birth control pills to suppress menstruation, and 74.7% of
them reported successfully preventing it. The average number
of pills used per day was 1.13 ± 0.45. The average start time for
taking medicine before menstruation was 10.37 ± 9.7; 51.5%
of participants received consulted regarding the pills, and
19.9% of them had no consultation at all before the pilgrimage.
Consultation was received by 42.4% of participants one week,
14.7% two weeks, 6.8% three weeks, and 36.7% more than
21 days prior to departing for Hajj. The average time before
departure for counseling was 22.23 ± 23.95 days (Table 1).
Despite taking medicine to postpone menstruation, 26% of
the participants reported spotting. Spotting was more frequent
in participants aged 25-45 years than participants under the
age of 25 years or over 45 years. Statistically, the differences
were significant at P = 0.03 (Table 2). The average start time
for spotting was on the eleventh day of the menstrual cycle
(11 ± 11.88). Also, 11.6% of the individuals taking medicine

Methods Table 1. Sample Frequency in Terms of Job, Educational Background,

This descriptive study considered 400 female Iranian pilgrims Prevention Method, Counseling and the Time of it
aged 15-50 years who did not have an intrauterine device
Variables No. Percent
(IUD). The participants were selected through random cluster
sampling from Umrah caravans. The size of the population Job
was determined to be 350 people based on similar studies, but Teacher 56 14.2
for the sake of higher reliability 400 participants were studied. Housewife 210 53.2
The exclusion criteria included women who were reluctant Student 74 18.7
or unwilling to participate in the study. The instrument Employee 55 13.9
used in this study was a two-part questionnaire developed Total 395 100
by the researchers and based on pilgrims’ complaints and Educational background
questionnaires from prior studies. The first section contained Illiterate 8 2
questions regarding personal characteristics, and the second Lower than diploma 76 18.7
section involved questions about methods of menstruation Diploma 141 34.6
prevention, symptoms of menstrual disorders, spotting, and Bachelor’s degree 151 37.1
treatment precautions. The questionnaire included 3 open- Higher than a bachelor’s degree 31 7.8
ended questions about the side effects of the medicine, the
Total 407 100
emotional effects of the resultant disorder, and the impact the
Prevention method
resultant disorder had on the performance of Umrah rituals.
No prevention 106 25.3
The questionnaire consisted of 23 questions, 5 regarding
Pill 302 72.1
demographic data, 15 regarding menstruation and medicine
consumption for menstrual suppression, and 3 open-answer Injection 5 1.2
questions which addressed side effects and problems. Injection and pill 6 1.4
Content validity of the questionnaire was checked through Total 419 100
the opinions of 3 gynecologists and 3 faculty members of the Counseling
Rafsanjan University of Medical Sciences. The reliability of Doctor 168 51.5
the questionnaire was 0.84. The questionnaire was distributed Midwife 60 18.4
among the participants at their hotels 3 days before their return Friends 33 10.1
to Iran. Random cluster sampling was used to randomly select No counseling 65 19.9
hotels and the Iranian caravans staying in them. Women Total 326 100
from each caravan volunteered to distribute and collect the Time of counseling
questionnaires. The collected data was inserted into SPSS One week before departure 75 42.4
version 18 software and analyzed using parametric and non- One to two weeks before departure 26 14.7
parametric tests such as the chi-square test.
Two to four weeks before departure 16 9.1
One to two months before departure 56 31.6
Results
More than two months 4 2.2
Four hundred female Umrah pilgrims participated in the
Total 177 100
study. The average age of the participants was 34.4 ± 1.33; 19.2

112 International Journal of Travel Medicine and Global Health. 2016;4(4):111–114

 Menstrual Suppression Using Oral Contraceptives

Table 2. Spotting Frequency by Age Group

Spotting No Spotting Total

Age
No. Percent No. Percent Percent No.
Less than 25 16 18.8 69 81.2 100 85
25-45 61 33 124 67 100 185
More than 45 6 14 37 86 100 43

Table 3. Comparison of Delay in Menstruation and Educational Background

Menstruation Delay No Menstruation Delay Total

Educational Background
No. Percent No. Percent No. Percent
Illiterate 5 62.5 3 27.5 8 100
Lower than diploma 51 67.1 25 32.9 76 100
Diploma 107 75.9 34 24.1 141 100
Bachelor’s degree 122 80.8 29 19.2 151 100
Higher than a bachelor’s degree 22 70.9 9 29.1 31 100

to postpone menstruation reported menstruation. To obviate
spotting, 74.6% had referred to a doctor; of those individuals,
61.6% reported their spotting was obviated and 27.9%
reported increasing the dose of the medicine to obviate this
problem.
Among the participants, 41% of those who consumed
medicine experienced at least one medicinal side effect,
mostly sickness and vomiting.
There was no significant difference between menstruation
delay and individuals’ educational background; however, the
rate of medicine consumption was higher among persons
holding a college degree (Table 3). There was no significant
difference at P  ˃ 0.05 between menstruation delay and factors
such as marital status and the dispatch city in Iran. There was
a significant difference between the consumption of medicine
and the age category; fewer participants over the age of 45
years took medicine than the others.
Qualitative analysis of the open-ended questions showed
that spotting and menstruation were reported as stressful for
participants in performing Umrah rituals. Some participants
reported menstruation as causing feelings of their visit to the
Ka’beh being rejected by God and expressed experiencing
great stress and anxiety.
Discussion
Results of the current study indicated that 74.7% of the
female pilgrims successfully prevented menstruation during
their pilgrimage to the Ka’beh (God’s house in Mecca), and
most of them reported using contraceptive pills to prevent it.
Currently, the long-term use of contraceptive pills to decrease
the occurrence of menstruation has been of great interest to
researchers and women of reproductive age. Large numbers
of women from all over the world prefer to take contraceptive
pills to prevent menstruation for many days.5,8
Despite taking pills, 26% of the pilgrims participating in the
current study experienced spotting and 11.6% menstruated.
The average start time for spotting was on the eleventh day
of the menstrual cycle. Spotting is a common side effect of
contraceptive pills, even in the common 21-day method
of using them.9 Most cases of spotting in this study can be
attributed to the short interval between starting medication
and spotting. Since contraceptive pills have a low amount of
estrogen in them, a low dose of conjugated estrogen is easily
used to alleviate the problem of spotting. Furthermore, with
the low dose of conjugated estrogen, the user is not disposed
to the side effects of the higher hormone dosage.
In a study by Sulak et al on 318 patients, they found that the
pills decrease the symptoms of PMS in 13%, hypermenorrhea
19% and headache 35%.10 Other studies which applied extended
and continuous regimens for preventing menstruation reported
a high and variable prevalence of spotting and bleeding;
however, these unwanted side effects were eliminated after a
few cycles. A high prevalence of side effects was reported in
women who used contraceptive pills for the first time.
Ghorashi et al reported the occurrence rates of spotting
and menstrual bleeding in Hajj pilgrims in 2000 as 13.6% and
2.1%, respectively.11 The low occurrence of these side effects
in the study of Ghorashi et al compared with the results of the
present study can be attributed to the high dose of the pills
taken by participants. In the study of Ghorashi et al, about
20% of the individuals took HD pills from the beginning, and
the others took two LD pills simultaneously.
In the present study, more than half of the individuals aged
over 45 years had used hormonal medicines to postpone
menstruation. An increase in the age of the user increased
the side effects of the contraceptive pills.8 Moreover, most of
the middle-aged women in this study suffered from diseases
like diabetes or hypertension, both of which can endanger
the consumption of contraceptive pills. Therefore, special
training and care for postponing menstruation, such as the
use of non-estrogenic pills, should be allocated to this group.
Statistically, there was no significant difference between
the start time for taking pills and the occurrence of spotting.
Therefore, those women who had a delayed start in taking pills
during their menstrual cycle did not report the occurrence
of spotting any more than those who started taking the
pill on the fifth day of their menstrual cycle. Furthermore,
Ghorashi et al found no significant difference between these
two variables. It can be concluded that the delay in starting
medicine consumption did not create additional problems for
the users. This will be helpful for those who tend to decrease
the consumption of the pill for different reasons. Therefore,

International Journal of Travel Medicine and Global Health. 2016;4(4):111–114 113

Dandehbor et al
decreasing the number of pills can help decrease their side
effects.7
About 20% of the participants in this study who had used
menstruation postponement methods had received no
counseling on the use of medicine before starting consumption.
From those who reported receiving counseling, more than
60% reported receiving counseling a short time (three
weeks or less) before the pilgrimage. It should be noted that
unadvised use of contraceptive pills among those who are at a
high risk can be dangerous or even deadly. Furthermore, the
unadvised use of contraceptive pills can lead to inappropriate
consumption, the possibility of increased side effects, and a
lack of necessary instruction on how to cope with side effects
such as spotting. Therefore, it is suggested that counseling be
taken into account in justification classes.
It is recommended that justification classes be held duly
and more than one month before the pilgrimage to allow
women to make better decisions about how to postpone
menstruation.
The most common side effect of taking contraceptive pills
noted in this study was vomiting, which is a prevalent side
effect of contraceptive pills.12 Because of the short period of
consumption and the specificity of the occasion, it is essential
to advise pilgrims on possible side effects of contraceptive
pills and the necessity of having them during the pilgrimage.13
Since the Hajj pilgrimage is an important and sometimes
exclusive event in the life of most pilgrims, the experience
of menstrual disorders during pilgrimage can be stressful,
disappointing, and problematic for them.14 To reduce such
problems, holding counseling sessions on menstruation
postponement as a part of the justification classes before
departure for Hajj and compiling an equal and coordinated
nationwide protocol seem necessary.15
Conclusion
The side effects of taking contraceptive pills for menstrual
suppression and their failures are considerable and cause
pilgrims to feel much stress and inconvenience. It is suggested
that this traditional approach be replaced with progestin-only
pills, such as megestrol.
Authors’ Contributions
All authors contributed significantly toward this study.
Conflict of Interest Disclosures
None declared.
Ethical Approval
Not applicable.
Funding/Support
There was no funding support for this research.
Acknowledgements
The authors would like to thank all the female pilgrims who
graciously completed the questionnaire in the short time of
their pilgrimage.
References
1. Al-Ghamdi AS, Kabbash IA. Awareness of healthcare workers
114 International Journal of Travel Medicine and Global Health. 2016;4(4):111–114
View publication stats
Research Highlights
What Is Already Known?
It is already known the side effects of taking contraceptive
pills for menstrual suppression and their failures are
considerable and cause pilgrims to feel much stress and
inconvenience. This review elaborates on the effects of
contraceptive pills on travelers.
What This Study Adds?
The results of the current study suggest that the traditional
approach of using contraceptive pills to suppress
menstruation should be replaced with the consumption of
progestin-only pills, such as megestrol pills. It is essential
that pilgrims be advised about the possible side effects
of the pills and the necessity of having them during the
pilgrimage.
regarding preventive measures of communicable diseases among
Hajj pilgrims at the entry point in Western Saudi Arabia. Saudi
Med J. 2011;32(11):1161-1167.
2. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS.
Pattern of admission to hospitals during muslim pilgrimage (Hajj).
Saudi Med J. 2003;24(10):1073-1076.
3. Azarpazhooh MR, Rafi S, Etemadi MM, Khadem N, Fazlinejad A.
The relation between short-term oral contraceptive consumption
and cerebrovascular, cardiovascular disorders in Iranian women
attending Hajj. Saudi Med J. 2008;29(7):1024-1027.
4. Bakhsh AR, Sindy AI, Baljoon MJ, Dhafar KO, Gazzaz ZJ, Baig
M, et al. Diseases pattern among patients attending Holy Mosque
(Haram) Medical Centers during Hajj 1434 (2013). Saudi Med J.
2015;36(8):962-966. doi:10.15537/smj.2015.8.12120.
5. Berek JS. Novak’s Text Book of Gynecology. 13th ed. Baltimore:
Williams & Wlkins; 2002:250-261.
6. Burkman RT. Oral contraceptives current status. Clin Obstet
Gynecol. 2001;44(1):62-72. doi:10.1097/00003081-200103000-
00010.
7. Madani TA, Ghabrah TM, Al-Hedaithy MA, et al. Causes of
hospitalization of pilgrims in the Hajj season of the Islamic year
1423 (2003). Ann Saudi Med. 2006;26(5):346-51.
8. Mansour D, Experiences with Yasmin; the acceptability of a novel
oral contraceptive and its effect on well being. Eur J Contracept
Reprod Health Care. 2002; 7 Suppl 13:35-41.
9. Elachola H, Assiri A, Turkestani AH, et al. Advancing the global
health security agenda in light of the 2015 annual Hajj pilgrimage.
Int J Infec Dis. 2015. doi:10.1016/j.ijid.2015.10.003.
10. Sulak PJ, Kuehl TJ, Ortiz M, Shull BL. Acceptance of altering the
standard 21-day/7day oral contraceptive regimen to delay menses
and reduce hormone withdrawal symptoms. Am J Obstet Gynecol.
2002;186(6):1142-1149.
11. Ghorashi Z, Taleghani F, Shafiee M. Failure and side effects of
contraceptive pills used for postponement of menstrual bleeding
in Hajj Pilgrims of Kerman (2000). JSSU. 2005;12(4):65-70.
12. Riaz SA, Ahmadi M, Mortazavi SM. Predictors of anxiety and
depression among women with vaginal bleeding referred to
gynecology clinic during hajj 2011. Iran Red Crescent Med J.
2014;16(11):e12855. doi:10.5812/ircmj.12855.
13. Masood K, Gazzaz ZJ, Ismail K, Dhafar KO, Kamal A. Pattern
of psychiatry morbidity during Hajj period at Al-Noor specialist
hospital. Int J Psychiatry Med. 2007;37(2):163-172.
14. Mohammed-Durosinlorun A, Raji HO, Hussain NA, Badmus SA,
Ijaiya MA. Menstrual suppression among female Nigerian pilgrims
during Hajj. J Fam Plann Reprod Health Care. 2012;38(4):270-
271. doi:10.1136/jfprhc-2012-100401.
15. Tin SS, Wiwanitkit V. Hajj pilgrimage surveillance in pilgrims
from African countries. Trop Med Int Health. 2015;20(2):E11.
doi:10.1111/tmi.12413.